| |
A stable partner slows progression of HIV
|
| |
| |
British Medical Journal Jan 3, 2004
In people infected with HIV, having a stable partner slows the progression of disease. During three years' follow up of 3736 HIV positive Swiss patients (Swiss HIV Cohort Study group) who had received highly active antiretroviral therapy, Young and colleagues found that 80% of the patients had a stable partner at some time, and these patients had a slower rate of progression to AIDS or death. Though having a stable partner results in lower mortality in HIV positive patients, the mechanisms responsible are not known.
"..For a healthcare professional caring for someone with HIV, the absence of a stable partnership indicates that this patient may progress more rapidly through clinical latency to the later stages of the disease."
"Stable partnership and progression to AIDS or death in HIV infected patients receiving highly active antiretroviral therapy: Swiss HIV cohort study"
Cohort studies have shown that social relationships influence mortality. Having fewer close friends or relatives, less frequent contact with other people, and reduced social participation have all been associated with increased mortality, especially in elderly people and in men. People living alone have a higher mortality from cardiovascular disease and a poorer prognosis after a cardiac event. However, little is known about the impact of social relationships on outcome for people infected with HIV, most of whom are under 40 years old.
Social support, the emotional or tangible support available from other people, is one of the primary ways in which social relationships influence health. In particular, greater emotional support is strongly associated with lower mortality. Social support may have physiological effects on the neuroendocrine or immune systems. Poor social support has been linked to a more rapid decrease in CD4 cell counts in HIV infection. Social support may have psychological effects, such as reducing anxiety and depression. Social support may also moderate risk behaviours and improve adherence to treatment.
Little is known about the effect of social support on outcome in HIV infection. Most definitions of social support emphasise family ties or social activities,16 and these may be less relevant for people living with HIV. For many people with HIV, a partner may be the most important source of emotional and tangible support. We investigated the association between a stable partnership and disease progression in HIV infected people receiving highly active antiretroviral therapy (HAART).
SUMMARY
The study objective was to explore the association between a stable partnership and clinical outcome in HIV infected patients receiving highly active antiretroviral therapy (HAART).
This is a prospective cohort study of adults with HIV (Swiss HIV cohort study) at seven outpatient clinics throughout Switzerland. The patients studied were the 3736 patients in the cohort who started HAART before 2002 (median age 36 years, 29% female, median follow up 3.6 years). HAART became available to all residents of Switzerland in August 1996, when its cost was covered by compulsory health insurance.
Since 1993, patients enrolled have been asked at visits scheduled every six months whether they have had sexual intercourse with a stable partner
during the previous six months. From April 2000 on, this single question was asked as two separate questions (presence of stable partner and sexual intercourse with that partner) as part of a new questionnaire on sexual behaviour.
To evaluate patient outcomes the study used patient’s time to AIDS or death (primary endpoint), death alone, increases in CD4 cell count of at least 50 and 100 above baseline, optimal viral suppression (a viral load below 400 copies/ml), and viral rebound.
RESULTS: During follow up 2985 (80%) participants reported a stable partnership on at least one occasion. When starting HAART, 52% (545/1042) of participants reported a stable partnership; after five years of follow up 46% (190/412) of participants reported a stable partnership. In an analysis stratified by previous antiretroviral therapy and clinical stage when starting HAART (US Centers for Disease Control and Prevention group A, B, or C), the adjusted hazard ratio for progression to AIDS or death was 0.79 (95% confidence interval 0.63 to 0.98) for
participants with a stable partnership compared with those without. Adjusted hazards ratios for other endpoints were 0.59 (0.44 to 0.79) for progression to death, 1.15 (1.06 to 1.24) for an increase in CD4 cells of 100 counts/µl or more, and 1.06 (0.98 to 1.14) for optimal viral suppression.
The study authors concluded that a stable partnership is associated with a slower rate of progression to AIDS or death in HIV infected patients receiving HAART.
We can only speculate about the reasons why a stable partnership is associated with a slower rate of disease progression for people with HIV. The increased rate of progression to a CD4 cell increase and to viral suppression in patients with stable partners may be linked to drug adherence. People with a stable partner may have less depression, a risk factor in many other chronic diseases. Research is needed on the mechanisms through which social support could influence HIV infection and should focus on mechanisms that are amenable to intervention. Increased support from healthcare givers might improve outcome in HIV infected people, but the evidence from one randomised trial in chronic cardiac patients does not support this hypothesis.
AUTHORS
Jim Young, biostatistician1, Sabina De Geest, professor of nursing3, Rebecca Spirig, senior research fellow3, Markus Flepp, reader in internal medicine4, Martin Rickenbach, epidemiologist5, Hansjakob Furrer, reader in internal medicine6, Enos Bernasconi, head of unit7, Bernard Hirschel, professor of infectious diseases8, Amalio Telenti, professor of infectious diseases9,
Pietro Vernazza, reader in internal medicine10, Manuel Battegay, professor of infectious diseases2, Heiner C Bucher, professor of clinical epidemiology1 Swiss HIV Cohort Study Group
1 Basel Institute for Clinical Epidemiology, University Hospital Basel, Hebelstrasse 10, Basle, CH-4031, Switzerland, 2 Division of infectious Diseases and Hospital
Hygiene, University Hospital Basel, 3 Institute of Nursing Science, University of Basel, Basle, 4 Division of Infectious Diseases, University of Zurich, Zurich,
Switzerland, 5 Data Centre of the Swiss HIV Cohort Study, University of Lausanne, Lausanne, Switzerland, 6 Division of Infectious Diseases, University Hospital Berne, Berne, Switzerland, 7 Ambulattorio malattie infettive, Ospedale Civico, Lugano, Switzerland, 8 Division des maladies infectieuses, Hôpital Universitaire de Genève, Geneva, Switzerland, 9 Division des maladies infectieuses, Centre Hospitalier Universitaire Vaudois, Lausanne, 10 Division of Internal Medicine, Cantonal Hospital Saint Gall, Saint Gall, Switzerland
|
|
| |
| |
|
|
|
